Provider Demographics
NPI:1508420175
Name:BRUNSON, AMANDA (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 11TH AVE STE A2
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1318
Mailing Address - Country:US
Mailing Address - Phone:850-461-3167
Mailing Address - Fax:850-979-8775
Practice Address - Street 1:1 11TH AVE STE A2
Practice Address - Street 2:
Practice Address - City:SHALIMAR
Practice Address - State:FL
Practice Address - Zip Code:32579-1318
Practice Address - Country:US
Practice Address - Phone:850-461-3167
Practice Address - Fax:850-979-8775
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW160621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical